Thrombolytic Therapy

Administration and Dosage

The American College of Cardiology recommends administering streptokinase as 1.5 million units diluted in 100 mL of normal saline and infused intravenously over 30-60 minutes for acute myocardial infarction 1, 2, 3
An initial bolus of 250,000 units given over 30 minutes, followed by continuous infusion of 100,000 units/hour is suggested by the American College of Cardiology 4

Prior streptokinase exposure within the past 6 months is an absolute contraindication due to risk of allergic reactions, as stated by the American Heart Association and American College of Cardiology 1, 3, 2, 5
A history of streptococcal pharyngitis within the past 6 months, active bleeding or bleeding diathesis, recent stroke, intracranial or intraspinal surgery, suspected aortic dissection, and significant head/facial trauma within 3 months are contraindications, as listed by the American Heart Association 1, 6

Streptokinase achieves 60-68% patency rates (TIMI 2-3 flow) at 90 minutes, as reported by the European Society of Cardiology 1, 3
Monitoring hemodynamic parameters every 2-3 hours during infusion, and performing Doppler echocardiography every 2-3 hours for obstructive prosthetic valve thrombosis is recommended by the American College of Cardiology 4

Unfractionated heparin or fondaparinux should be administered as an anticoagulant with streptokinase, as suggested by the European Society of Cardiology 2, 7
Aspirin (150-325 mg orally or 250-500 mg IV) and clopidogrel (300 mg loading dose if ≤75 years; 75 mg if >75 years) should be given along with anticoagulation therapy, as recommended by the European Society of Cardiology 8, 7

The following anticoagulation regimens can be used:

Anticoagulant	Dosage
Unfractionated heparin	60 U/kg IV bolus (maximum 4000 U) followed by IV infusion of 12 U/kg/hr (maximum 1000 U/hr) for 24-48 hours
Fondaparinux	IV bolus followed by a subcutaneous dose 24 hours later
Enoxaparin	30 mg IV bolus followed 15 minutes later by a subcutaneous dose for patients ≤75 years, and no IV bolus with a reduced subcutaneous dose for patients >75 years

Streptokinase antibodies can persist for years after exposure, potentially reducing efficacy and increasing allergic reaction risk, as noted by the American College of Cardiology 1, 3, 2, 5
Streptokinase should be administered within 12 hours of symptom onset for optimal outcomes in STEMI, with greatest benefit seen when given within the first 3 hours, as recommended by the American College of Cardiology and European Heart Society guidelines 3, 2
Surgery can be performed 24 hours after discontinuation of streptokinase infusion, as stated by the American College of Cardiology 4
GP IIb/IIIa inhibitors should not be administered with streptokinase, as there is no evidence of benefit and bleeding risk may increase, as recommended by the European Society of Cardiology 7
Prasugrel and ticagrelor should not be used as adjuncts to fibrinolysis, as they have not been studied and may increase bleeding risk, as recommended by the American College of Cardiology 7